Helge Garåsen The Trondheim Model - NSDM

As the study in question dealt with elderly patients with complex medical and social
problems, it was decided early in the planning phase of the study that the primary outcomes
should be relevant for different categories of health professionals at both community and
general hospital level; i.e. both classical medical as well as more socially oriented fields in a
broader health context. To deliver services according to the older patients’ needs, all
professions and teams have to cooperate with the patient, and all must understand and agree
on the best form of follow-up care for each patient.
In fields were there is insufficient information and possibly contradictory interests, consensus
methods can be reliable methods to synthesize information (36-37), so it was decided to
combine the Delphi technique with the nominal technique (37,118).
When planning the study, we had some problems finding references using expert panels to
assess outcomes as most of the earlier studies have used questionnaires. There were also some
difficulties finding references to all of the relevant outcomes to our study. Nearly all earlier
studies on the quality of referral and discharge letters have focused on physicians’ needs or
the inappropriateness of hospital stays based on hospital physicians’ points of view, and not
so much on the needs of the community health teams so that they and the patient himself can
plan necessary home care. The assessments of the quality of the referral and discharge letters
were performed on the following objects:
• Medical history
• Symptoms
• Signs
• Actual medical situation/status
• Medication
• ADL
• Reason for being hospitalised
• Social network
o Family
o Social functional ability
o Home care
o Family physician
• Follow-up responsibility
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